Denials and appeals

Revenue erosion and denials are often easily prevented, but simple errors may evade traditional, reactive denials management processes. Apply these tips to reduce and prevent common denials due to medical necessity, the three-day payment window, and more.

The 3-day payment rule is known to coders by various names such as the 72-hour rule, the 3-day payment window, or MS-DRG window policy. Kimberly Lee M.Ed., RHIA, CCS-P, describes how to navigate the rule’s nuances for billing purposes.

Every organization’s priorities will differ, but any outpatient CDI program must determine how to measure the improvement associated with its efforts. Outpatient CDI will directly contribute to the facility’s overall quality performance and risk adjustment models.

Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. Refresh your knowledge of this modifier with coding tips and example scenarios.

Coding managers should not assume that they can review every coding guideline, Coding Clinic, or coding-related issue targeted by the Office of Inspector General. Review considerations for conducting focused internal and external audits.

Hospitals have made avoiding and managing denials a top priority, but for many their best efforts have yet to turn the tide.

Clinical validation denials can be complex and difficult to appeal. Improve your process by using these tips to craft a clinical validation appeal.

Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, unpacks local and national medical necessity standards and best practices for avoiding denials due to inadequate documentation.

Fran Jurcak, MSN, RN, CCDS, CCDS-O, looks at how machine learning can improve efficiency in the middle revenue cycle.

Tiffany Ferguson, LMSW, ACM, and Marie Stinebuck, MBA, MSN, ACM, CEO and COO at Phoenix Medical Management Inc., discuss why the best strategy to prevent denials related to medical necessity is a proactive approach that focuses on front-end processes.